There are no systems that are human proof, and what kind of human behavior is tolerated is a characteristic of the system.
In fact, there are humans that lie, cheat, are apathetic, and incompetent. Part of a good system is to not only mitigate, but actively weed these people out.
For example, if someone falsifies the inspection checklist for your plane, you dont just give them a PIP.
Why is it important to you?
I see lots of engineers and QA following a elaborate procedures with hundreds of checks, but not bothering to even read what they sign off on, so they can go golf all day.
People seem to think that you can engineer some process flow to prevent every error, but every process is garbage if the humans dont care or know what they are doing.
Every process is garbage is you dont hire workers with the right skills demanded by that process. In an effort to drive down costs, lots of companies try to make up for talent with process, with poor results, for both the companies and patients. you cant replace a brain surgeon with 2 plumbers and twice the instructions.
Similarly, I read some head of a leading engineering organization (I think a NASA head or maybe Admiral Rickover) who said, essentially, 'you can't replace ability with process'. All the process in the world, they said, will not substitute for highly able personnel.
But perhaps safety, not usually dependent on ability, is a different matter. Possibly, the problems you describe are a matter of leadership and management - which doesn't undermine your point; those also are things that can't, past a certain irriducible point, be replaced with process.
I wholeheartedly agree that leadership/management is a part of problem. My main objection is the "no bad employee" rhetoric. Sometime times the problem with management is that they aren't getting rid of bad employees. Rot can start anywhere in an organization, and the rest of the org really needs to push back, not just management.
It actually reminds me a lot of the culture/discipline problems with some Police departments in the US. It is hard to enforce and cultivate organizational culture top down. Most of it is maintained peer-peer.
> It is hard to enforce and cultivate organizational culture top down. Most of it is maintained peer-peer.
I think it's a combination. The leader has a large influence; they set the standards and the norms. At the same time, I agree with what you say about peers - perhaps peers spread and 'enforce' those norms. It may also depend on the size and age of the organization.
A lot of bad management is hand-waved as crappy employees (by management - shocking!)
If you are talking about someone who cant server coffee, the balance is clearly in favor of poor management over inadequate skills and trainability.
If you are talking about very specialized skills like aerospace engineering, I think the balance can move further in the other direction.
There is also the combination of the two, where in the interests of growth or cost savings, an organization has cut corners on the quality of talent hired.
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